Provider Demographics
NPI:1437984309
Name:BOLDEN, LEESA DIAN (LAC)
Entity type:Individual
Prefix:
First Name:LEESA
Middle Name:DIAN
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1361
Mailing Address - Street 2:
Mailing Address - City:QUARTZSITE
Mailing Address - State:AZ
Mailing Address - Zip Code:85346-1361
Mailing Address - Country:US
Mailing Address - Phone:512-784-6929
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1361
Practice Address - Street 2:
Practice Address - City:QUARTZSITE
Practice Address - State:AZ
Practice Address - Zip Code:85346-1361
Practice Address - Country:US
Practice Address - Phone:512-784-6929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-001125171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist